What to do if an elderly patient with glaucoma experiences recurrent epistaxis (nosebleed) while waiting to see a healthcare provider?

Management of Recurrent Epistaxis in an Elderly Patient with Glaucoma

An elderly patient with glaucoma experiencing recurrent epistaxis while awaiting specialist evaluation should receive immediate first-line treatment with firm nasal compression for 10-15 minutes, followed by topical vasoconstrictors if bleeding persists, while avoiding systemic decongestants that could worsen glaucoma. 1, 2

Immediate First-Line Management

• Position the patient sitting upright with head tilted slightly forward to prevent blood from flowing into the airway or being swallowed 1, 2
• Apply firm, continuous compression to the soft lower third of the nose for a full 10-15 minutes without checking if bleeding has stopped 1, 2
• Instruct the patient to breathe through their mouth and spit out any blood rather than swallowing it 1, 2

This compression alone resolves the vast majority of anterior epistaxis cases and is the only intervention required in most instances. 1, 2

If Bleeding Persists After 15 Minutes

• Clear the nasal cavity of blood clots by suction or gentle nose blowing 2
• Apply topical vasoconstrictor spray (oxymetazoline or phenylephrine) - 2 sprays into the bleeding nostril 2, 3
• Resume firm compression for another 5-10 minutes after applying the vasoconstrictor 2

Topical vasoconstrictors stop bleeding in 65-75% of emergency department cases through local vasoconstriction. 2

Critical Glaucoma-Specific Considerations

Topical nasal vasoconstrictors (oxymetazoline, phenylephrine) are safe for glaucoma patients because systemic absorption is minimal. 2, 3 However, avoid recommending oral decongestants or systemic sympathomimetics, as these can increase intraocular pressure and worsen glaucoma.

Risk Stratification for This Population

Elderly patients with recurrent epistaxis require heightened vigilance because:

• Advanced age dramatically increases epistaxis severity and complications 4
• This age group has significantly higher rates of posterior epistaxis (more difficult to control, greater morbidity) 4
• 45% of hospitalized epistaxis patients have underlying systemic diseases contributing to bleeding 4

Document these critical risk factors: 2, 4

• Anticoagulant or antiplatelet medications (aspirin, warfarin, DOACs, clopidogrel)
• Hypertension (present in 24-64% of epistaxis patients)
• Personal or family history of bleeding disorders
• Nasal oxygen or CPAP use
• Intranasal medications or drug use
• Prior nasal/sinus surgery

When to Seek Immediate Medical Attention

The patient should go to the emergency department if: 1, 2

• Bleeding does not stop after 15 minutes of continuous manual pressure
• The patient becomes lightheaded or dizzy from blood loss
• Signs of hemodynamic instability develop (tachycardia, hypotension, pallor, syncope)
• Bleeding duration exceeds 30 minutes over a 24-hour period
• Active bleeding from nose or mouth despite proper compression

Blood Pressure Management Pitfall

Do NOT aggressively lower blood pressure acutely during active epistaxis. 4 While hypertension is common in epistaxis patients, routine acute blood pressure reduction can cause or worsen renal, cerebral, or coronary ischemia in elderly patients with chronic hypertension. 4 Monitor blood pressure but base control decisions on bleeding severity, individual comorbidities, and risks of reduction. 4

Prevention of Recurrence While Awaiting Specialist

Once bleeding stops: 2

• Apply petroleum jelly or other moisturizing agents to the nasal mucosa twice daily
• Use saline nasal sprays frequently throughout the day to keep mucosa moist
• Run a humidifier, especially in dry environments
• Avoid nose picking, vigorous nose-blowing, and nasal manipulation for 7-10 days

Anticoagulation Considerations

If the patient is taking anticoagulants or antiplatelet medications: 1, 2

• It is reasonable to seek care from a healthcare professional unless bleeding has completely stopped 1
• Do NOT discontinue anticoagulation for standard epistaxis alone - most cases resolve with local measures 2
• For aspirin in high-risk cardiovascular patients (recent MI, stents), continue aspirin despite epistaxis as survival benefits outweigh bleeding risks 2
• If on warfarin, check INR to evaluate therapeutic range; supratherapeutic levels may require specialty consultation for severe refractory bleeding 4

Advanced Interventions if Initial Measures Fail

If bleeding persists despite compression and vasoconstrictors: 2

• Perform anterior rhinoscopy after clot removal to identify the bleeding site
• Consider nasal cauterization if a specific bleeding site is identified (requires healthcare professional)
• Nasal packing may be necessary - use only resorbable materials (Nasopore, Surgicel, Floseal) if patient is on anticoagulants 2

Red Flags Requiring Specialist Evaluation

Arrange urgent ENT consultation if: 2, 4

• Recurrent bilateral nosebleeds (consider hereditary hemorrhagic telangiectasia)
• Unilateral epistaxis with nasal obstruction, facial pain, or visual changes (concern for mass lesion)
• Bleeding is difficult to control despite appropriate measures
• Patient requires nasal packing
• Posterior epistaxis is suspected (more common in elderly, requires endoscopic evaluation)